So You Want to Be a Gastroenterologist

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So you want to be a gastroenterologist. You like the idea of poop, the digestive tract, and more poop. Let’s debunk the public perception myths, and give it to you straight. This is the reality of gastroenterology.

 

What is Gastroenterology?

Gastroenterology is the specialty within medicine focused on the gastrointestinal system, including everything along the alimentary canal. It’s the only field that’s truly mouth to anus, covering not only the entire gastrointestinal tract, but also the pancreas and the liver.

The conditions you will manage include inflammatory bowel disease, or IBD, not to be confused with irritable bowel syndrome, or IBS, which you’ll also treat. Colon cancer, which, excluding skin cancer, is the third most common form of cancer among men and women in the United States, will also fall under your preventative screening and management. Gastroenterologists deal with dysphagia, which means difficulties with swallowing, and anything relating to nutrition. After all, the gut is where we absorb nutrients and water. Liver diseases, such as liver cancer, cirrhoses, and hereditary pathologies such as hemochromatosis or alpha-1 trypsin deficiency fall under GI care, as do pancreatic diseases such as pancreatitis or pancreatic cancers.

Ultimately, gastroenterology is a subspecialty of internal medicine, and having a strong foundation in internal medicine is essential to be an effective GI doctor. After all, many of the GI conditions and pathologies you’ll encounter are closely involved with other parts of the body. For example, the liver is intimately connected with the adrenal system and kidneys. The brain-gut is another intimate association that can influence your patient’s symptoms and disease course.

Gastroenterology is a unique subspecialty of internal medicine, as it combines a high degree of clinical continuity and longitudinal care with procedural medicine, something that few other specialties provide — cardiology is one such example. While not a surgical subspecialty, Gastroenterologists work with their hands routinely. Gastroenterologists perform endoscopies, colonoscopies, ERCP’s, and biopsies of virtually any abdominal organ via endoscopic ultrasound. Moreover, it is now quite common to have many procedures, previously only addressed by surgeons, now performed endoscopically as it is often less invasive for sicker patients – these might include drainage of abscesses, placement of a luminal stent, or a nissen fundoplication. You’ll work with either pediatric or adult patients, and you’ll be dealing with both acute and chronic processes. These acute processes will be anything but boring: bleeding gastric ulcers are high acuity and can be life threatening, and you will regularly remove foreign bodies, including toy cars or phallic shaped objects that someone “accidentally slipped on.” From the top end, poorly chewed meat, dentures, chicken bones, and even silverware will require your expertise in removing safely.

There are a few ways of categorizing gastroenterology.

Academic vs Community vs Private Practice

As an academic gastroenterologist, you’ll be focused on teaching students and GI fellows, in addition to contributing to the academic side of medicine. In academia, you typically see more variety in pathology, unique cases, and rare hereditary diseases.

As a community gastroenterologist, working in a smaller institution, you’ll be dealing with more bread and butter cases that tend to be less complicated or unique. If you’re at a county hospital, where patients often don’t seek medical help until much later, you might see more rare, advanced pathophysiology and presentations.

Private practice is the least common practice setting for a gastroenterologist, and it usually only occurs in smaller towns. It’s more difficult to manage because there are multiple moving parts in a GI practice, including both acute and chronic as well as procedural and non-procedural aspects. Coordinating staff, clinic, and most importantly patient safety, such as cleaning scopes, proper sedation, and having state of the art equipment, makes private practice increasingly cumbersome.

Outpatient vs Inpatient

As an outpatient gastroenterologist, you’ll have the more standard 9 to 5 or 8 to 4 working hours and a predictable schedule. This offers flexibility with your lifestyle, including better hours, and a high degree of clinic time and procedures, primarily in diagnostic screenings, such as a colon cancer screening colonoscopy. You’ll generally spend 3 or 3 and a half days doing procedures each week, and 1 and a half to 2 days in clinic. The majority of your work will be outpatient in nature, but you’ll be on call with the local hospital or academic center for emergencies a few times per month.

As an inpatient gastroenterologist, you’re likely to be working in academia. Again, this translates to teaching medical students, residents, and fellows, and also seeing more advanced pathologies. You’ll be busier than your outpatient colleagues, and patients will be sicker. It’s more rigorous, but for many the rewards pay off — primarily in teaching and involvement with more intricate procedures, such as ERCP in dealing with the liver and pancreas. In terms of your schedule as a GI in academia, you can typically expect to work from 9 AM to 6 PM depending on inpatient rounds, in addition to being on call at night a few times each month.

If you are a GI hospitalist, you can expect one week on and one week off, like an internal medicine inpatient hospitalist.

Misconceptions about Gastroenterology

Gastroenterology is a fascinating field. After I was diagnosed with inflammatory bowel disease over 10 years ago, I was actually inspired to pursue pediatric gastroenterology so that I could help children with similar digestive disease processes. I was drawn to the procedural elements and found nutrition and digestion fascinating, but I ended up pursuing plastic surgery.

Many people think that because of the colonoscopies and other procedures within GI, it’s a field that’s hard on your nose. The truth is, it rarely smells bad because patients are generally prepped beforehand, meaning their colons are cleaned with laxatives to improve visualization of the colon walls.

While GI is technically mouth to anus, you’ll find in practice that it more practically begins at the upper esophageal sphincter. Above that, it’s primarily ENT, also known as otolaryngology, although there is some overlap between the two.

And yes, digital rectal exams are important, and if you’re a medical student or resident don’t shy away from them. And for the rest of you, make sure you’re comfortable with poop if you’re considering GI.

 

How to Become a Gastroenterologist

To become a gastroenterologist, you first complete 4 years of medical school, then 3 years of internal medicine residency, and then 3 years of gastroenterology fellowship. That’s a total of 6 years of postgraduate training after medical school. Many gastroenterologists also pursue an additional 1 or 2 year fellowship to further subspecialize.

Gastroenterology is one of the most competitive internal medicine fellowships, duking it out with cardiology. They do consider all three USMLE scores, including Step 1, Step 2CK, and Step 3 in assessing your application. Research is also highlighted, with the average matriculant having 11 research items, compared to 9 for cardiology. This isn’t so much a rite of passage, but rather highlighted because gastroenterology is a rapidly changing and evolving field. Hot topics in gastroenterology right now are related to new endoscopic surgical techniques such as POEM, or Peroral Endoscopic Myotomy, an endoscopic procedure used to treat swallowing disorders, most commonly for Achalasia. Another hot topic is the gut microbiome as it relates to various aspects of health, including the gut. There is also attention focused on developing oral medications rather than intravenous medications for ease of administration for patients, especially for those with inflammatory bowel disease.

If pediatric gastroenterology is your goal, then you’d first complete three years of pediatrics residency rather than internal medicine residency. After that, you would complete 3 years of pediatric gastroenterology fellowship.

If you’re interested in doing surgery on the digestive tract, you want to look to general surgery and its subspecialties, such as colorectal or hepatobiliary surgery. That’s a separate residency training process, whereby you match into general surgery first and complete the relevant fellowship after.

As for the medical students who typically go for gastroenterology, they’re usually the ones who enjoy a fast paced specialty, are efficient, yet are also laid back and can handle the sometimes high acuity and stressful situations. They’re adaptable and versatile, being able to turn on and quickly lock in for an acute bleed, but also able to slow down for clinic.

 

Subspecialties within Gastroenterology

Most of the gastroenterology fellowships are 1 year in duration, although some programs are 2 years, particularly if they have a heavier focus on research. Note that with any of these fellowships, you’ll still be treating general gastroenterology conditions and performing screening colonoscopies in varying amounts.

Interventional/Advanced Endoscopy

Interventional and advanced endoscopy focuses on endoscopic procedures, such as endoscopic retrograde cholangiopancreatography, or ERCP, to visualize the gallbladder, biliary system, pancreas, and liver.

You’ll also be trained in endoscopic ultrasound, which is similar to endoscopy, but rather than a camera at the end, you’ll have an ultrasound probe. Ultrasound is commonly done from the outside of the body, but endoscopic ultrasound offers internal imaging that’s highly accurate, and is used to diagnose cancer, take biopsies, or place enteral stents.

Advanced endoscopists do a great deal of stenting when cancers obstruct the GI passages, whether in the esophagus, stomach, small intestine, or colon. In these instances, your interventions are more therapeutic or palliative, rather than curative.

It’s a highly rewarding subspecialty, but it comes with longer hours and is often inpatient in nature. You’ll also be wearing lead aprons for long periods of time for frequent use of x-rays, which can be tiresome, particularly when also maneuvering the scope.

Inflammatory Bowel Disease

Inflammatory bowel disease is an autoimmune condition, consisting of two types: Crohn’s disease and ulcerative colitis. With an autoimmune disease, the body is attacking itself, and these are the specialists in managing the heavy hitting and sometimes dangerous immunosuppressive agents that get this disease under control. It’s a rapidly evolving field, taking a closer look at how the gut microbiome influences these conditions. You’ll also be dealing with awesome patients like me.

In terms of lifestyle, hours are more predictable and involve a typical 9 AM to 5 PM schedule in nature.

Hepatology & Transplant Hepatology

Hepatology and transplant hepatology are the experts on the liver, dealing with liver cirrhosis, autoimmune diseases of the liver, hereditary diseases, and liver failure.

While the transplant surgeon will be doing the actual harvesting and surgery, you’ll be evaluating the patient for liver transplant candidacy and will provide pre-op and post-op care. Often times, this includes stabilizing and improving a patient’s health from first presentation such that they are realistic liver transplant candidates. This requires careful attention and nuance to medication management and peri and post operative care.

Motility

Motility is the least common of GI fellowships, dealing with peristalsis of the gastrointestinal tract, meaning the wavelike motion that propels food down the alimentary canal. These coordinated contractions push stomach contents into the small intestine, or help the colon and rectum move feces prior to having a bowel movement. Peristalsis is reliant on the nervous system, endocrine system, and balance between sympathetic and parasympathetic systems.

Motility experts are often working with various systemic conditions that impair motility, such as neurologic diseases or scleroderma, an autoimmune connective tissue disease that causes hardening of the skin and other tissues.

 

What You’ll Love About Gastroenterology

There’s a lot to love about gastroenterology. It uniquely offers a good breadth of medical knowledge applied in both the acute and chronic settings. If you enjoy procedures but don’t quite want to do surgery, consider this specialty.

If you’re into exciting high acuity situations, there’s plenty of GI emergencies through acute bleeds and foreign body ingestion. On the other hand, you’ll also enjoy longitudinal care and forging relationships with your patients, as many GI diseases are chronic in nature.

Mastery is inherently rewarding, and my gastroenterologist friend says it’s a very easy specialty to master, assuming you have a strong foundation in internal medicine first.

In terms of compensation, it’s usually in the top 6 specialties, most recently at $419,000 per year, which makes sense given its procedural nature. You have flexibility with your lifestyle and are able to have a 9 AM to 5 PM schedule while making a very comfortable living.

There’s currently a widespread shortage of gastroenterologists in many cities, and therefore you’ll be in high demand, giving you leverage in having the type of practice you want.

 

What You Won’t Love About Gastroenterology

While GI is an amazing specialty, it’s not for everyone. If you are disgusted by the idea of feces, look elsewhere. It’s not a constant reality that you’ll be facing every minute of the day, but you’ll be seeing at least a little bit on a daily basis.

It can be a fast-paced field, and you should be comfortable being able to jump around from clinic to rushing to the ED for an acute GI bleed, and then going to the procedure suite to do your scopes for the day. If you prefer a slow-paced specialty, this may not be a good fit.

The specialty deals with a high number of chronic diseases, and these patients often require more patience. You are often unable to quickly fix and cure someone of their ailment — if that’s what you’re looking for, then surgery would be better suited for you.

And lastly, I’ll touch on my own personal experience. When I was pursuing GI, I spent a great deal of time in the procedure suite, watching dozens of upper and lower endoscopies. I knew that I wanted to do something procedural, but the procedural variety is limited in something like GI, and it doesn’t compare to surgery in terms of complexity, nuance, and technical challenge. That’s not to take anything away from GI. It’s simply a nature of the different approaches — in surgery, you’re completely hands on, touching, cutting, suturing various layers of tissue. In comparison, with gastroenterology you’re always separated to a larger degree, as the scope or other tools place you much further from the action.

 

Should You Become a Gastroenterologist?

How can you know if gastroenterology is the right field for you? If you’re a fun, friendly, laid back person that enjoys the benefits of a balanced lifestyle, flexibility with your practice type or location, while also making a good living, gastroenterology might be a good fit for you. Gastroenterologists are often outgoing and friendly, as they’re constantly interacting with others, both patients and colleagues in other specialties.

It’s a very procedural specialty, so if you’re comfortable with that and not terrified of poop, you may have found your match.

Are you interested in gastroenterology? It’s one of the most competitive fellowship options of internal medicine, and you’ll need to be a strong candidate to have reasonable odds. If you’re a premed hoping to gain acceptance to medical school, you should do whatever you can to stand out and do your best on the MCAT, as it’s one of the most important and heavily weighted objective measurements in your medical school application. Designed by two 99.9th percentile scoring physicians, including yours truly, and built from the ground up using the latest in learning science, Memm users have been blown away by how effective it is at improving their scores. Don’t take my word for it. Visit the Memm blog to read interviews with prior users or check out our customer reviews on TrustSpot.  Visit memm.io to learn more.

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